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Developing people

for health

and healthcare

Doctors and Dentists in Difficulty

Health Education North West

Written by Dr Joanne Rowell Associate Dean

Version 1.1 (November 2014)

Developing people

for health

and healthcare Doctors & Dentists in Difficulty

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Definition

‘Any trainee who has caused concern to his or her Educational Supervisor about the ability

to carry out their duties, and which has required unusual measures to be put into place. This

would mean anything outside the normal trainer – trainee processes where the Training

Programme Director (TPD) has been called upon to take or recommend action’.

Early recognition of problems, appropriate intervention with effective feedback and support

for both trainee and trainer are most likely to be successful. In each case, thorough and

careful investigation is essential to determine the nature of the problem and identify

underlying factors before appropriate action can be taken.

Difficulties usually present as Performance Issues, the range of which can be considerable.

More often than not there is an inter-play between several factors including: conduct,

health, personal circumstances and the learning environment that leads to poor

performance.

Potential initial triggers raising concern

Initial concerns are as likely to be apparent to nursing and other clinical staff, other trainees

or senior grade doctors/dentists as they are to the trainee’s clinical or educational

supervisor. However, it may be difficult for peers or other colleagues to take any action if

there is not a clear and confidential channel of communication available. Initial triggers

raising concerns may include:

Patterns and repetition rather than one – off incidents

Sudden, ‘out of character’ behaviour with no obvious explanation

Higher than expected levels of sickness

One-offs that are more serious, but which the trainee feels able to easily rationalize.

For example, ‘’a small lie’’; ‘’only cheated that one time’’; ‘’some slight exaggeration

on the CV’’.

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Behavioural markers which may indicate a trainee requires

extra supervision or support

(Adapted from a report from an NCAS meeting on Doctors in Difficulty: Recognising

Problems Early (J. Firth-Cozens, 2004)

1. Work based:

Absence from duty / persistent lateness / Presenteism

Poor time management / backlog of work

Failure to learn and change

2. Clinical performance markers:

Over or under investigating

Poor decision making

Poor record keeping

Complaints

Failure to follow guidelines

Missed diagnosis

3. Cognitive:

Memory problems

Poor problem solving / reasoning

Decision-making difficulties

Poor concentration / attention

Learning problems

4. Language / Cultural:

Poor verbal fluency

Poor understanding

5. Psychological / Personality:

Irritability

Unpredictability

Forgetfulness

High self-criticism / perfectionist

Arrogance

Lack of insight / denial

Risky / impulsive

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6. Social:

Isolation

Withdrawal

Poor personal interactions

Do not minimise or underestimate the importance of early signs

Trust and act on your instincts – if something ‘feels wrong’ it probably is

Problems can arise at any time

Acting early when a problem arises could rescue rather than destroy a career

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LEVELS of CONCERN

(Adapted from the Revalidation Support Team, 2011)

LEVEL 1

A concern raised to an educator by any colleague, clinical supervisor or by the education

supervisor themselves.

No harm to patients, trainee or staff

No risk to patients, trainee, staff or their reputations

Examples:

Incidents

Complaints

Failure to attain expected training goals

Self limiting or well controlled chronic illness

Actions:

Discussion with trainee

Consider pastoral support

Minor investigation e.g. gather information which then can be fed back

to the trainee to give them the opportunity to respond

Action plan with SMART* educational outcomes

Resolution over short period of time

Management:

A level 1 concern should be dealt with locally, documented by the Educational Supervisor

and passed on to the TPD. Referral to HR for foundation trainees or the appropriate Lead

Employer Team who may wish to involve Occupational Health for all other trainees. For

Foundation trainees, please inform the Foundation Team and patch Associate Dean /

Associate Dental Director / Associate GP Director at Health Education North West (HENW)

so that appropriate support and advice can be facilitated.

If a level 1 type incident recurs the Educational Supervisor should then treat the concern as

level 2 and refer into HENW.

*SMART = Specific, Measurable, Achievable, Realistic, Timely

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LEVEL 2

A concern raised to an educator by any colleague, clinical supervisor or by the educational


Potential or actual harm to patients, trainee or staff

Potential or actual risk to patients, trainee, staff or their reputations

Examples: As level 1 plus:

Recurrent or persistent behavioural issues

Any issue requiring an extension of training e.g. health

Actions: As level 1 plus;

Formal investigation

HR involvement

OH involvement

Action plan with defined objectives

Special interventions

Management:

A level 2 concern should be referred into HENW using the local referral protocol:

For foundation trainees, the Foundation Programme Director or Director of Medical

Education should refer to the patch Associate Dean using Form F1

For specialty trainees, the Training Programme Director or Head of School should refer to

the specialty Associate Dean using Form S1. The appropriate Lead Employer Team

should also be notified of the concerns.

For dental trainees, the Training Programme Director should refer to the Associate Dental

Director using Form D1

Consideration for inclusion into the Doctors and Dentists Review Group will then be made by

the Foundation School Director, Director of Postgraduate Hospital Medicine, Dental Director

or GP Director in consultation with the Associate Deans/Associate Dental Director or

Associate Directors managing doctors and dentists in difficulty.

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LEVEL 3

A concern raised to an educator by any colleague, clinical supervisor or by the educational


Harm has occurred to patients, trainee or staff

Reputations (personal / corporate) are at serious risk

Examples: As level 2 plus;

Serious Untoward Incident

Formal complaint

Death

Criminal act e.g. theft, assault

Consideration of a GMC / GDC / NCAS referral*

Action: As level 2 plus:

Formal investigation

Situation dependent but including consideration of cessation, or

restriction of, clinical practice

Management:

Direct referral to the Postgraduate Dean and the appropriate Lead Employer Team, via the

Dental Director or specialty Associate Dean/Director (as above) or, in the event of an

emergency, direct to the Postgraduate Dean / local Responsible Officer.

Formal referral to the Doctors and Dentists Review Group (via Forms F1, S1 or D1 as

above).

*The Postgraduate Dean must be informed of the likely referral

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Recording information

Once a concern has been raised it is vital that detailed factual records are kept from the

beginning of the process in order to support action which may need to be taken as the case

progresses. This can take the form of:

Trainee e-portfolio

Own notes of meetings or discussion with colleagues relating to the

trainee

Own notes of meetings or discussions with the trainee

Documents produced by other colleagues

An initial fact finding internal review should take place to gather all relevant information. This

information should be documented as above. If performance is normally good, a change in

health, personal circumstances or environmental factors should be considered.

Consideration as to whether the problem is a health, conduct or performance (or multiple

issues) should be undertaken.

It is then vital that the Foundation Programme Director (FPD) / Training Programme Director

(TPD) makes a referral to the appropriate specialty Associate Dean/Director or Dental

Associate Director using Form F1 (Foundation), S1 (Specialty) or D1 (Dental) (attached),

with a copy to Head of School (not in the case of dental). This will facilitate early

identification of trainees who may require extra support or training if problems persist.

The TPD / FPD should inform the following departments or individuals of the trainee

requiring support, as appropriate, and coordinate the ongoing communication trails between

the relevant bodies as appropriate:

Clinical Supervisor (CS)

Educational Supervisor (ES)

Head of School (HoS) / Dental Associate Director

Specialty Associate Dean (AD) (via Form F1 or S1)

Occupational Health (OH) via the Lead Employer Team.

Lead Employer Team

Medical Director / Director of Medical Education (MD/DME)

(responsibility of the Lead Employer Team for non-FY trainees)

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Once the Specialty Associate Dean (AD) has been informed, they will be classed as the

“case supervisor” for that case and will liaise with the TPD, HoS, Patch AD and AD with

responsibility for doctors with performance issues and will liaise with the Doctors and

Dentists Review Group as appropriate.

Document concerns raised in a factual and contemporaneous manner

This can help inform further intervention and act as an

aide memoir for the future

Any written documents are disclosable

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Form F1 – Foundation Trainees

Doctors in Difficulty

This form is to be completed by the appropriate FPD following a trigger incident of Level 2 or

3 concern. A fact finding exercise should initially take place to aid completion of the form.

Forward the completed form to the Director and/or Associate Dean of Foundation Training

and to your local patch AD

* delete as appropriate

Date of Initial Concern:

Name of Trainee:

Date of Birth:

Gender:

Ethnicity:

GMC Number:

Current Trust / Post:

Trainee Training Level:

Appointment Process: National* HENW* Local*

Medical School: Date of Graduation:

Transfer of Information: Tier 4 (if applicable):

Start date of Foundation:

Outcome of previous ARCP/ FY Sign off:

Description of Issues Identified and action taken:

Progress through training so far (ARCP outcomes, career support, significant time out of programme

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etc):

Other departments / agencies involved (e.g. occupational health, human resources, named links at HENW etc):

Have these issues been discussed with the trainee and are they aware of this referral?

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Form S1 – Specialty Trainees

Doctors in Difficulty

This form is to be completed by the appropriate TPD following a trigger incident of Level 2 or


Forward the completed form to the specialty AD.


Name of Trainee:

Date of Birth:

Gender:

GMC Number:

Current Trust / Post:

Trainee Training Level:

Placement Details (starting with the most recent:

Date Location Specialty RITA / ARCP

Current Educ Supervisor:


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Progress through training so far (ARCP outcomes, career support, significant time out of programme etc):

Other departments / agencies involved (e.g. occupational health, lead employer, named links at HENW etc):


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Form D1 – Dental Trainees

Dentists in Difficulty

This form is to be completed by the appropriate TPD following a trigger incident of Level 2 or


Forward the completed form to the Director of Dental Training.

* delete as appropriate


Name of Trainee:

Date of Birth:

GDC Number:

Foundation Scheme:

FY2 / CDP:

NTN: if applicable

Specialty:

Trainee Training level:

Start date:

Outcome of previous ARCP/ FY Sign off:


Progress through training so far (ARCP outcomes, career support, significant time out of programme etc):

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Other departments / agencies involved (e.g. occupational health, lead employer, named links at HENW etc):
